Techniques to reduce blood loss during open myomectomy: a qualitative review of literature

The Effect of Intravenous Tranexamic Acid on Myomectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Myomectomy is the preferred surgical treatment for symptomatic women with uterine myomas who wish to preserve their fertility. The procedure may be associated with significant intraoperative blood loss, which predisposes to increased transfusion rates and morbidity. The objective of our systematic review and meta-analysis is to investigate whether intravenous (IV) use of tranexamic acid (TXA) may reduce blood loss during myomectomy. Three electronic databases were screened until June 2022. The eligible studies were assessed for risk of bias. Four randomized controlled trials that reported outcomes from a total of 310 women were finally included in the meta-analysis—155 patients received intravenous TXA while the remaining 155 received placebo injection with normal saline or water for injection. Total estimated blood loss was significantly lower in patients who received TXA before myomectomy compared to control (230 patients MD −227.09 mL 95% CI −426.26, −27.91, p = 0.03). This difference in favor of TXA group remained when intraoperative and postoperative blood loss was separately analyzed. Postoperative hematocrit values and hemoglobin levels did not differ among the two groups (180 patients MD 0.67% 95% CI −0.26, 1.59, p = 0.16 and 250 patients MD 0.17 mg/dL 95% CI 0.07, 0.41, p = 0.17, respectively). The number of patients that received blood transfusion was also not different (310 patients OR 0.46 95% CI −0.14, 1.49, p = 0.19). Total operative time was significantly prolonged in control group compared to TXA (310 patients MD −16.39 min 95% CI −31.44, −1.34 p = 0.03). Our data show that the IV use of TXA may significantly reduce intraoperative blood loss in patients undergoing myomectomy and contribute to reduced operative time.

Can the application of a temporary uterine tourniquet during an abdominal myomectomy reduce bleeding?

Objective

Uterine fibroids are common, benign uterine tumours. The three most common surgical treatment approaches for uterine fibroids are laparoscopic, robotic and abdominal myomectomies. Bleeding is a risk with all three approaches. The present study compared post-operative and pregnancy outcomes in patients with bilateral uterine artery occlusion who underwent an abdominal myomectomy, with or without a temporary uterine tourniquet.

Material and Methods

This retrospective study included patients with intra-mural fibroids (≥5 cm) who underwent an abdominal myomectomy. The patients were divided into two groups according to the use or non-use of a temporary uterine tourniquet. Post-operative and pregnancy outcomes in the tourniquet use and non-use groups were compared. The association of the number of uterine fibroids removed (≤3 vs >3) with laboratory parameters was also evaluated.

Results

A total of 84 patients were included, divided into use (n=36) and non-use (n=48) of the temporary tourniquet. There was a statistically significant difference between the groups with >3 myomas removed and with a uterine tourniquet applied and not applied in terms of reduction in hemoglobin and hematocrit, transfusion amounts, operation times and lengths of hospitalization in favour of the uterine tourniquet use group (p=0.019, p=0.023, p=0.012, p=0.044 and p=0.036, respectively). Bilateral uterine arterial occlusion using a temporary uterine tourniquet had no negative effects on pregnancy outcomes.

Conclusion

A temporary uterine tourniquet may be an effective method for reducing the amount of perioperative bleeding in patients with multiple, large-sized myomas located close to vascular structures.

Safety and efficacy of lidocaine plus epinephrine on intraoperative bleeding in abdominal myomectomy: A double-blind clinical trial

Background

Uterine fibroid is a common benign pelvic tumor and abdominal myomectomy may cause excessive intraoperative bleeding, which may lead to adverse outcomes.

Objective

This study was planned to evaluate the effectiveness of the injection of lidocaine plus epinephrine to reduce intraoperative bleeding in abdominal myomectomy.

Methods

During October 2019 and May 2020, 60 eligible women with uterine fibroids were enrolled in a randomized controlled trial. Our patients were divided into two groups of lidocaine plus epinephrine defined as Group L and placebo defined as Group P. In group L, lidocaine 3 mg/kg plus 0.5 ml of adrenaline which reached to 50 cc with saline solution and in group P, 50 ml of normal saline was used. Both the combined solution and normal saline were infiltrated to the serous and myometrium above and around the fibroid before incision. Patients' demographic data, total operative time, hemoglobin changes, and the degree of surgical difficulty were evaluated and compared between the two groups.

Results

There was no significant difference between the two groups in terms of demographic data. Hemoglobin changes (p <  0.0001) and the degree of surgery difficulty (p = 0.01) were significantly lower in Group L compared with Group P. In each group the drop in hemoglobin levels from baseline to 4 h postoperatively was significant (p <  0.0001). A significantly meaningful correlation was reported between hemoglobin changes and the degree of surgery difficulty with the size of the uterine and fibroids (p < 0.05). While a negative correlation was found regarding gravidity and surgery difficulty (r = -0.413, p = 0.02). Surgery duration was longer in Group P compared with Group L 70.66 ± 19.85 versus 66.16 ± 14.48, respectively, but with no significant difference (p = 0.32). No significant adverse reaction or serious complication was reported in the two groups. Hemodynamic parameters were kept in the normal range throughout the surgery.

Conclusion

A combination of lidocaine plus epinephrine during abdominal myomectomy appears to be a safe and effective method in reducing blood loss.

Single-port access (SPA) laparoscopic myomectomy with uterine artery ligation via a retroperitoneal approach is feasible in women with large uterine leiomyoma

OBJECTIVE

Uterine artery ligation (UAL) at the time of myomectomy has shown to decrease blood loss during the operation. However, little is known about the efficacy and feasibility of UAL during single-port access (SPA) myomectomy. The present study was performed to investigate the clinical benefits of UAL in SPA myomectomy and to provide details of the surgical techniques.

MATERIALS AND METHODS

A retrospective and comparative review on the surgical outcomes of the patients who underwent SPA myomectomy with UAL and those who underwent SPA myomectomy without UAL was conducted. UAL was performed at its origin from the internal iliac artery via a retroperitoneal approach.

RESULTS

A total of 56 women who received SPA myomectomy were reviewed (24 patients received SPA myomectomy with UAL while 32 patients received SPA myomectomy only). The median weight of total resected leiomyomas was heavier for the patients who received UAL than those who did not receive UAL [210.0 g (range: 171.5-335.0 g) vs. 119.0 g (62.5-265.0 g), p = 0.023]. However, no differences in total operative time, estimated blood loss, perioperative hemoglobin changes, use of postoperative analgesics and postoperative complications between the two groups were seen.

CONCLUSION

Obtaining similar surgical outcomes between the patients who received UAL with larger leiomyomas and those who did not receive UAL with smaller leiomyomas suggests that UAL is a feasible surgical approach to reduce blood loss during SPA myomectomy. Detailed descriptions of the surgical techniques are provided in the present report.

The Number of Myomas Is the Most Important Risk Factor for Blood Loss and Total Operation Time in Robotic Myomectomy: Analysis of 242 Cases

To identify factors affecting blood loss and operation time (OT) during robotic myomectomy (RM), we reviewed a total of 448 patients who underwent RM at Seoul Asan Hospital between 1 January 2019, and 28 February 2021, at Seoul Asan Hospital. To avoid variations in surgical proficiency, only 242 patients managed by two surgeons who each performed >80 RM procedures during the study period were included in this study. All cases of RM were performed with a reduced port technique. We obtained the following data from each patient's medical chart: age, gravidity, parity, body mass index, and history of previous abdominal surgery including cesarean section. We also collected information on the maximal diameter and type of myomas, number and weight of removed myomas, concomitant surgery, total OT from skin incision to closure, estimated blood loss (EBL), and blood transfusion. Data on preoperative use of gonadotropin-releasing hormone agonists (GnRHas) and perioperative use of hemostatic agents (tranexamic acid or vasopressin) were also collected. Data on the length of hospital stay, postoperative fever within 48 h, and any complications related to RM were also obtained. The primary endpoint in this study was the identification of factors affecting EBL and the secondary endpoint was the identification of factors affecting the total OT during multiport RM. Univariate and multivariate analyses were used to identify the factors affecting EBL and OT during multiport RM. The medians of the maximal diameter and weight of the removed myomas were 9.00 (interquartile range [IQR], 7.00 to 10.00) cm and 249.75 (IQR, 142.88 to 401.00) g, respectively. The median number of myomas was two (IQR, one to four), ranging from 1 to 34. Of the cases, 155 had low EBL and 87 had high EBL. Most myomas were of the intramural type (n = 179). The odds of EBL > 320 mL increased by 251% (odds ratio [OR], 2.51; 95% confidence interval [CI], 1.16-5.42) for five to nine myomas and by 647% (OR, 6.47; 95% CI, 1.87-22.33) for ≥10 myomas. The odds of subserosal-type myomas decreased by 67% compared with intramural-type myomas (OR, 0.33; 95% CI, 0.14-0.80). History of abdominal surgery other than cesarean section was positively correlated with EBL. The weight of the removed myomas and a history of previous cesarean section were not correlated with the EBL. Conclusion: The number of myomas (5-9 and ≥10), maximal myoma diameter, and history of abdominal surgery other than cesarean section affect the EBL in RM.

Comparison of safety and efficacy between laparoscopic myomectomy and traditional laparotomy for patients with uterine fibroids and their effect on pregnancy rate after surgery

The aim of this retrospective study was to compare the safety and efficacy between laparoscopic myomectomy and traditional laparotomy for patients with uterine fibroids and determine their effect on the pregnancy rate after surgery. In total, 86 cases with uterine fibroids were selected among patients who were admitted in the Zhangqiu District Maternal and Child Health Care Hospital during the period of April, 2016 to April, 2017. Patients who underwent laparoscopic myomectomy were enrolled in group A (n=42), and those who underwent traditional laparotomy were placed in group B (n=44). The general linear data and the operative indicators were compared. The VAS scores, serum IFN-γ, IL-6, VEGF levels and clinical efficacy of the two groups were also compared one week after surgery. Postoperative pregnancy rates and complications in both groups were also compared. No significant differences were observed in general data between the two groups (P>0.05). The intra-operative blood loss in the group A was lower than that in group B (P<0.05), the average time of operation, hospital stays (days), and anal exhaust time in group A were shorter than those in group B (P<0.05). The pain degrees at 3, 6 and 18 h after surgery for patients in the group A were significantly lower than those of the group B (P<0.05). There was no significant difference IL-6 and VEGF levels in the serum between groups A and B before and after surgery (P>0.05); however, the level of IFN-γ expression, one week after surgery, in group B was significantly higher than that in group A (P<0.05). The pregnancy rate in the experimental group was higher than that in the control group (P<0.05), and the incidence rate of complications in group A was significantly lower than that in group B (P<0.05). Results presented in the present study suggested that compared to traditional laparotomy, laparoscopic myomectomy is a more advantageous method in terms of safety, efficacy and pregnancy rate after surgery.

New Surgical Technique for Robotic Myomectomy: Continuous Locking Suture on Myoma (LSOM) Technique

Robot-assisted laparoscopic myomectomy (RALM) has broadened the indications even in complex myomas. However, the high cost of RALM remains the main disadvantage. Therefore, a surgical technique that can reduce the cost of RALM and still has the advantages of robotic surgery is required. We propose a "locking suture on myoma (LSOM)" technique and compared the operative and perioperative outcomes of patients who underwent RALM with or without the LSOM technique. We included 337 patients who underwent RALM with (n = 160) or without (n = 177) the LSOM technique between March 2019 and August 2020. The LSOM group had low parity and gravidity, with a low rate of Cesarean sections. Myoma type was not different between the groups; however, patients in the LSOM group had larger, heavier, and higher number of myomas, although fewer patients had multiple myomas and were discharged earlier. Total operating time, estimated blood loss, pre- and postoperative hemoglobin levels, transfusion rate, and postoperative fever were not different between the two groups. In conclusion, the LSOM technique may be a viable surgical option for myomas, as it can reduce the cost of RALM by obviating the need for robotic Tenaculum forceps.

Uterine Isthmus Tourniquet during Abdominal Myomectomy: Support or Hazard? A Randomized Double-Blind Trial

BACKGROUND AND OBJECTIVES

A tourniquet has been suggested as a useful means of reducing massive hemorrhage during myomectomy. However, it is not clear whether the restricted perfusion affects the ovaries. In the present study, we examined the effect of a tourniquet on ovarian reserve and blood loss during myomectomy.

MATERIALS AND METHODS

In a randomized double-blind clinical trial, fertile nonobese patients scheduled for abdominal myomectomy at Rasool-e-Akram Hospital from February 2018 to June 2019 were randomized to a tourniquet (n = 46) or a non-tourniquet group (n = 35). Serum levels of anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH) were measured before and 3 months after surgery, blood loss was recorded during surgery, and serum levels of hemoglobin (Hb) were recorded before surgery, 6 h and 3 days after surgery. SPSS version 21 was used for statistical analysis.

RESULTS

Demographic, obstetric, and myoma characteristics were similar in the 2 groups (p > 0.05). The mean baseline values of AMH and FSH did not differ between groups (p > 0.05). After surgery, only FSH was higher in the control group (p = 0.043). Despite the time taken to fasten and open the tourniquet, the mean operating time was shorter in the tourniquet group (p < 0.001). Blood loss was higher in the control group (p = 0.005). The drop in Hb levels at 6 h after surgery was higher in the non-tourniquet group (p = 0.002). Blood loss was significantly associated with the duration of surgery (r = 0.523, p < 0.001).

CONCLUSION

The use of a tourniquet during abdominal myomectomy significantly reduced the mean volume of blood loss compared to the non-tourniquet group, while it did not prolong the duration of surgery, nor reduced the ovarian reserve. A tourniquet is a safe and efficient measure during abdominal myomectomy.

Misoprostol vs vasopressin as a single hemostatic agent in laparoscopic myomectomy: Comparable, or just better than nothing?

AIM

Laparoscopic myomectomy may be associated with considerable blood loss, especially in patients in whom no specific hemostatic measures are used. We conducted this retrospective comparative study to investigate whether misoprosol is an effective and safe alternative to vasopressin when used as single hemostatic agent in laparoscopic myomectomy.

METHODS

Two hundred cases undergoing laparoscopic myomectomy (-ies), were included. Of these, 50 pre-treated with vaginal misoprostol 400mcg 1 h before surgery (group 1), were compared with two historic consecutive groups: 100 patients treated with intraoperative intra-myometrial injection of dilute vasopressin (20 IU/100 mL normal saline) (group 2), and 50 treated without use of any hemostatic agent (group3).

RESULTS

Mean procedure length did not differ significantly between the three groups (127.9 vs 100.6 vs 130.8 min). Mean estimated blood loss (EBL) was 179.7 ± 200.0 mL in group 1, compared with 147.8 ± 171.8 mL in group 2 (P = 0.793) and 321.8 ± 246.0 mL in group 3, respectively (P < 0.001). EBL was lower in group 2 in most of the study's subgroups of patients stratified according to size and number of fibroids compared with group 1, with the exception of patients with ≥4 fibroids, and ≥7 cm in size. In these subgroups, misoprostol appeared more effective. Neither agent was associated with serious adverse events.

CONCLUSION

Vaginal misoprostol can be effective in reducing blood loss during laparoscopic myomectomy. Although rates of EBL are, in general, higher compared with those obtained with vasopressin, they are significantly reduced compared with those observed when no hemostatic agent is used. In extended procedures, vaginal misoprostol, due to its prolonged uterotonic action, may be associated with reduced blood loss compared with vasopressin.

Myomectomy associated blood transfusion risk and morbidity after surgery

OBJECTIVE

To evaluate blood transfusion risks and the associated 30-day postoperative morbidity after myomectomy.

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

Women who underwent myomectomies for symptomatic uterine fibroids (N = 3,407).

INTERVENTION(S)

Blood transfusion during or within 72 hours after myomectomy.

MAIN OUTCOME MEASURE(S)

The primary outcomes were rate of blood transfusion with myomectomy and risk factors associated with receiving a transfusion. The secondary outcome was 30-day morbidity after myomectomy.

RESULT(S)

The overall rate of blood transfusion was 10% (hysteroscopy, 6.7%; laparoscopy, 2.7%; open/abdominal procedures, 16.4%). Independent risk factors for transfusion included as follows: black race (adjusted odds ratio [aOR] 2.27, 95% confidence interval [CI] 1.62-3.17) and other race (aOR 1.77, 95% CI 1.20-2.63) compared with white race; preoperative hematocrit <30% compared to ≥30% (aOR 6.41, 95% CI 4.45-9.23); preoperative blood transfusion (aOR 2.81, 95% CI 1.46-5.40); high fibroid burden (aOR 1.91, 95% CI 1.45-2.51); prolonged surgical time (fourth quartile vs. first quartile aOR 11.55, 95% CI 7.05-18.93); and open/abdominal approach (open/abdominal vs. laparoscopic aOR 9.06, 95% CI 6.10-13.47). Even after adjusting for confounders, women who required blood transfusions had an approximately threefold increased risk for experiencing a major postoperative complication (aOR 2.69, 95% CI 1.58-4.57).

CONCLUSION(S)

Analysis of a large multicenter database suggests that the overall risk of blood transfusion with myomectomy is 10% and is associated with an increased 30-day postoperative morbidity. Preoperative screening of women at high risk for transfusion is prudent as perioperative transfusion itself leads to increased major postoperative complications.

Minimally Invasive Myomectomy: An Overview on the Surgical Approaches and a Comparison with Mini-Laparotomy

Uterine fibroids (UFs) are the most common benign solid tumors of the female genital tract manageable by surgical of pharmacological approach. When the medical management is ineffective or surgery is primarily requested, several surgical approaches can be used. Among these, minimally invasive surgery might be preferred. Myomectomy is the standard surgical treatment when fertility sparing is claimed. It can be performed via laparoscopy, robotic surgery and hysteroscopy and the choice depend on UFs features and surgeon's skill. Alongside these minimally invasive options, mini-laparotomy has been proposed as a less invasive surgical approach comparable to the well-established minimally invasive options. The aim of this review is to describe the most recent advances in minimally invasive techniques to perform myomectomy, comparing them with mini-laparotomy approach.

Transient Occlusion of Uterine Arteries in Procedures with High Risk of Uterine Bleeding

Introduction:

Uterine-conservative surgery via laparoscopy is a challengeable and high risk because of heavy intra-operative bleeding events in reproductive women with highly vascular uterine benign disease. There are three reported cases of women with highly vascular uterine benign diseases and high risk of intra-operative heavy bleeding, but were treated successfully to control intra-operative heavy bleeding risk by transient occlusion of the uterine artery (TOUA) through laparoscopy and resulted in safe conservation of the uterus.

Case Presentation:

The cases of women with high risk of heavy bleeding during therapeutic procedure included cesarean scar pregnancy, hydatid form mole on cesarean scar, and cervical pregnancy. All these women had the strong desire to presere their fertility and uterus. In all the three cases, we used the method of TOUA and performed therapeutic surgeries successfully, with less bleeding and safe conservation of the uterus through laparoscopy.

Conclusion:

Laparoscopic TOUA could be a therapeutic option to manage heavy intra-operative bleeding during conservative uterine surgeries associated with the risk of heavy bleeding.

[Prevention of bleeding during laparotomic myomectomy in Sub-Saharan Africa: Contribution to the tourniquet on the uterine isthmus]

OBJECTIVES

To appreciate the decrease of bleeding by myomectomy by the use of a tourniquet on the uterine isthmus.

METHODS

We conducted a case-control retrospective study from March 2014 to February 2016 in the Gynecology and obstetrics Department of the university hospital of Yopougon (Abidjan, Ivory Coast). It interested 100 patients of which 50 had a myomectomy with the tourniquet on the uterine isthmus and 50 without the tourniquet. None of the patients received pre-operative preventive treatment. The criteria for comparison were the blood loss per operative and the pre-and post-operative hemoglobin levels.

RESULTS

The average age of patients was 33 years. Nulliparous women were the group most affected (68% of our patients) with 32% infertile women in the group with the tourniquet and 18% in the group without the tourniquet. Patients without tourniquet presented more bleeding than patients with tourniquet (X2=13.61) with a higher proportion of anemic patients in the group without the tourniquet. The differences were significant. The tourniquet has made it possible to realize the resection of a larger number of myoma. The duration of hospital stay was 4 days on average in both groups and no complications were observed.

CONCLUSIONS

The application of a tourniquet on the uterine isthmus during laparotomic myomectomy has a benefit in reducing intraoperative blood loss.

Vasopressin during Laparoscopic Myomectomy: Does It Really Extend Its Limits?

STUDY OBJECTIVE

Τo investigate whether the use of vasopressin played an important role in the safe expansion of the indications of laparoscopic myomectomy in our practice.

DESIGN

A retrospective comparison of prospectively collected data (Canadian Task Force classification II2).

SETTING

A gynecologic endoscopy unit in a tertiary university hospital.

PATIENTS

One hundred fifty patients undergoing laparoscopic myomectomy; 50 were treated without the use of any vasoconstrictive agent (group 1), and 100 were treated with intraoperative intramyometrial injection of dilute vasopressin (20 IU/100 mL normal saline) (group 2).

INTERVENTIONS

Laparoscopic myomectomy.

MEASUREMENTS AND MAIN RESULTS

We compared the 2 groups in terms of size, number, and type of myomas; estimated blood loss (EBL); procedure length; transfusion rates; laparoconversion rates; and rates of complications. Two cases in group 1 (4%) were laparoconverted versus none (0%) in group 2. Overall, the mean EBL was 321.8 ± 246.0 mL in group 1 compared with 147.8 ± 171.8 mL in group 2, respectively (p <.001). Additionally, EBL was significantly lower in the vasopressin group in all of the study's subgroups of patients stratified according to the size and number of myomas. Procedure length did not differ significantly between the 2 groups (130.8 ± 49.5 vs 115.6 ± 49.4 minutes, p = .078). The risk factors for prolongation of the procedure included size and number of myomas independently of vasopressin. The rates of hypercapnea and subcutaneous emphysema were higher in group 1. The risk factors for hypercapnea and subcutaneous emphysema included the size and intramural position of the largest myoma. Vasopressin was not associated with serious cardiovascular adverse events.

CONCLUSIONS

Vasopressin is effective in reducing blood loss during laparoscopic myomectomy. Although experienced surgeons may achieve comparable operation times without vasopressin, even in the most challenging cases, blood loss may still be considerable. The occurrence of hypercapnea is higher in untreated cases and may contribute to laparoconversion.

Surgical management of a large neurilemmoma-like leiomyoma of the uterine cervix mimicking a retroperitoneal tumor

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A large cervical neurilemmoma-like leiomyoma can simulate a retroperitoneal tumor.

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They are extremely rare tumors that require adequate bleeding control.

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Comprehensive anatomo-pathological study should be done to rule out malignancy.

Robot-assisted laparoscopic myomectomy: current status

Robotic-assisted surgery has seen a rapid development and integration in the field of gynecology. Since the approval of the use of robot for gynecological surgery and considering its several advantages over conventional laparoscopy, it has been widely incorporated especially in the field of reproductive surgery. Uterine fibroids are the most common benign tumors of the female reproductive tract. Many reproductive-aged women with this condition demand uterine-sparing surgery to preserve their fertility. Myomectomy, the surgical excision of uterine fibroids, remains the only surgical management option for fibroids that entails preservation of fertility. In this review, we focus on the role of robotic-assisted laparoscopic myomectomy and its current status, in comparison with other alternative approaches for myomectomy, including open, hysteroscopic, and traditional laparoscopic techniques. Several different surgical techniques have been demonstrated for robotic myomectomy. This review endeavors to share and describe our surgical experience of using the standard laparoscopic equipment for robotic-assisted myomectomy, together with the da Vinci Robot system. For the ideal surgical candidate, robotic-assisted myomectomy is a safe minimally invasive surgical procedure that can be offered as an alternative to open surgery. The advantages of using the robot system compared to open myomectomy include a shorter length of hospital stay, less postoperative pain and analgesic use, faster return to normal activities, more rapid return of the bowel function, and enhanced cosmetic results due to smaller skin incision sizes. Some of the disadvantages of this technique include high costs of the robotic surgical system and equipment, the steep learning curve of this novel system, and prolonged operative and anesthesia times. Robotic technology is a novel and innovative minimally invasive approach with demonstrated feasibility in gynecological and reproductive surgery. This technology is expected to take the lead in gynecological surgery in the upcoming decade.

Fibroids that do not distort the uterine cavity and IVF success rates: an observational study using extensive matching criteria

OBJECTIVE

To assess the impact of non-cavity-distorting fibroids on in vitro fertilisation (IVF) pregnancy outcomes.

DESIGN

A retrospective, matched, single-centre, cohort study was performed.

SETTING

The IVF unit of a tertiary, university hospital.

POPULATION

We analysed all women with non-cavity-distorting uterine fibroids undergoing IVF/intracytoplasmic sperm injection (ICSI) cycles from 1 January 2011 to 1 May 2015.

METHODS

Each woman was matched with two separate controls of the same age (±6 months), stimulation protocol (gonadotropin-releasing hormone agonist or antagonist), starting dose of follicle-stimulating hormone (FSH), number of embryos transferred (one or two), day of transfer (day 3 or day 5), and no uterine fibroids identified by transvaginal ultrasound.

MAIN OUTCOME MEASURES

Clinical pregnancy and live birth rates.

RESULTS

Our study demonstrates that the presence of non-cavity-distorting fibroids appears to negatively affect clinical pregnancy (odds ratio, OR 0.62; 95% confidence interval, 95% CI 0.41-0.94) and live birth rates (OR 0.58; 95% CI 0.48-0.78) in patients undergoing their first IVF/ICSI cycle, when matched with controls of the same age, starting dose of FSH, stimulation protocol, number of embryos, and day of embryo transfer. The deleterious effect of fibroids on live birth rates was significant in women with two or more fibroids (OR 0.47; 95% CI 0.26-0.83) and in women with fibroids of ≥30 mm in diameter (OR 0.41; 95% CI 0.19-0.89). The negative impact of non-cavity-distorting fibroids was also present in women with an embryo transfer on day 5 (OR 0.58; 95% CI 0.35-0.94). Conversely, in women with single fibroids of <30 mm in diameter, no difference in pregnancy outcomes was identified.

CONCLUSIONS

A well-designed, adequately powered, randomised controlled trial is required to address the role of medical or surgical interventions in patients with intramural and subserosal fibroids before undergoing fertility treatment.

TWEETABLE ABSTRACT

Non-cavity-distorting fibroids negatively affect pregnancy rates after IVF.